Name: Fill this form out COMPLETELY, this will document medical necessity for insurance companies, PLEASE PRINT...we need to read it!
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- Holly Webb
- 5 years ago
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1 Fill this form out COMPLETELY, this will document medical necessity for insurance companies, PLEASE PRINT...we need to read it! Where is your pain located? What does your pain interfere with? How would you describe your pain? Aching, Burning, Gnawing, Stabbing, Throbbing, Sharp, Dull, Numbing Things that make the pain WORSE (circle): Nothing, Sitting, Standing, Lying Down, Walking, Lifting, Carrying, Twisting, Pushing/Pulling, Gripping, Grasping, Squeezing, Throwing, Weight Bearing, Exercise, Previous Surgery, Computer Use, Changing Clothes, Getting out of Bed, Going from Sitting to Standing, Cold/Damp Weather Things that make the pain BETTER (circle): Nothing, Sitting, Standing, Lying Down, Position Change, Heat, Ice, Rest, Elevation, Exercise, Stretching, Limited Weight Bearing, PT/OT, Chiropractic Care, Epidural, OTC Medications, Narcotics, NSAIDS, Cortisone Injection, Orthotics, Previous Surgery, Brace, Sling Previous Procedures and Results: Present Illness: Cause of present pain complaint Pain Rating on a scale of 0 to 10: Today: 0 No pain Worst At Lowest: 0 No pain Worst At Highest: 0 No pain Worst tilt dfir, r.,.k%s i2.i;: 'i.(7.,. ;,
2 List all Healthcare Professionals Consulted with Include Physical Therapy, Occupational Therapy, Psychotherapy, Chiropractic, Dentistry, Podiatry, Previous Injections. Past Surgical History All surgeries since birth, include month/year. Medications All medications currently taking, with DOSES AND NUMBER OF TIMES TAKEN PER DAY. Allergies Medication allergies and reaction to each drug. Iodine or contrast dye? Yes or No Latex? Yes or No Family Medical History Family members major medical problems. Include pain problems, arthritis, unusual joint flexibility, cancer, heart attack, stroke, high blood pressure, diabetes, seizures, substance abuse, psychological illnesses. Social History Tobacco use: Yes/No/Former How much? Years of Use: When did you quit? Advanced Directive: Yes/Ṅ o Alcohol use: None/Occasional/Moderate/Heavy/Former When did you quit? Chewing Tobacco: Yes/No List Illegal Drug Use: Present Occupation: Work Related Injury: Yes/No Auto Related Injury: Yes/No Currently Pregnant: Yes/No/NA Marital Status: Educational Level Disability: Yes/No How long? What For?
3 REVIEW OF SYSTEMS: CIRCLE ALL THE AREAS YOU PRESENTLY HAVE PROBLEMS WITH. Constitutional: Weight Gain Weight Loss Loss of Appetite Fever Fatigue ENMT: Snoring Hearing Loss Difficulty Swallowing Sinus Problems Cardiovascular: High blood pressure Hx Irregular Heartbeat Heart Murmurs Blood Clot Chest Pain Limb Swelling Artificial Heart Valve Defibrillator/Pacemaker Poor Circulation Respiratory: Cough Wheezing Shortness of Breath Hx of Asthma COPD/Emphysema Endocrine: Hx of Thyroid Problems Gastrointestinal: Ulcers Vomiting/Nausea Irritable Bowel Syndrome (IBS) Hx of Diabetes Frequent Diarrhea Constipation GERD Liver/Pancreas Problems Gallbladder problems Genitourinary: Urinary Loss of Control Urinary Hesitation Urinary Infections Painful urination Kidney failure/dialysis Allergic/Immunologic: Allergic Reactions to Medications Seasonal Allergies Psychological: Hx of Depression Physical/Sexual Abuse Bi-Polar Hallucinations Substance/Alcohol Abuse Anxiety Hematology/Lymphatic: Swollen Glands/Nodes Easy Bruising/Bleeding Hx of Cancer Anemia Immunosuppressed Disease HIV/AIDS Musculoskeletal: Muscle Aches Muscle Weakness Joint pain Back Pain Swelling in Extremities Integumentary: Itching/Burning Rash/Sores Fix of Eczema/Psoriasis.Neu ruiugicai: Headaches/Migraines Memory Loss Loss of Strength Numbness Dizziness Seizures Poor Concentration Functional: Wheelchair Shower grab bars Walker Adaptive equipment Power chair Ramp into house Walking Problems Cane Toilet grab bars Is there anything else you would like the Doctor to know?
4 SOAPP-R The following are some questions given to patients who are on or being considered for medications for their pain. Please answer each question as honestly as possible. There is no right or wrong answers. 1. How often do you have mood swings? 2. How often have you felt a need for higher doses of medication to treat your pain? 3. How often have you felt impatient with your doctors? 4. How often have you felt that things are just too overwhelming that you can't handle them? 5. How often is there tension in the home? 6. How often have you counted pain pills to see how many are remaining? 7. How often have you been concerned that people will judge you for taking pain medications? _ 8. How often do you feel bored? 9. How often have you taken more pain medication than you are supposed to? 10. How often have you worried about being left alone? 11. How often have you felt a craving for medication? 12. How often have others expressed concern over your use of medications? 13. How often have any of your close friends had a problem with alcohol or drugs? 14. How often have others told you that you had a bad temper? 15. How often have you felt consumed by the need to get pain medications? 16. How often have you run out of pain medication early? 17. How often have others kept you from getting what you deserve? 18. How often, in your lifetime, have you had legal problems or been arrested? _ 19. How often have you attended an AA or NA meeting??o. HMA/ oftpn haves yrill been in an n rg i, m.nt that %.,,c s,-,,,.t of control that someone got hurt? 21. How often have you been sexually abused? 22. How often have others suggested that you have a drug or alrnhnl prnhinm? 23. How often have you had to borrow pain medications from your family or friends? 24. How often have you been treated for an alcohol or drug problem? _ Never Seldom Sometimes Often Ver y Often , Please feel free to add any additional information you wish about the above answers. Thank You.
5 Date : Oswestry Function Questionnaire Score: This questionnaire gives your provider information about how your pain affects your ability to manage everyday activities. Please answer every section by circling the number that most closely applies to you. Please only circle ONE NUMBER that most closely describes your situation. 1- PAIN INTENSITY 0. My pain is mild to moderate: I do not need pain killers. 1. The pain is bad, but I manage without taking pain killers. 2. Pain killers give me complete relief from pain. 3. Pain killers give me moderate relief from pain. 4. Pain killers give me very little relief from pain. 5. Pain killers have no effect on my pain. 2- PERSONAL CARE 0. I can look after myself normally without causing extra pain. 1. I can look after myself normally but it causes extra pain. 2. It is painful to look after myself and I am slow and careful. 3. I need some help but manage most of my personal care. 4. I need help everyday in most aspects of self-care. 5. I do not get dressed, wash with difficulty and stay in bed. 3- LIFTING 0. I can lift heavy weights without extra pain. 1. I can lift heavy weights but it gives extra pain. 2. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, ex: on a table. 3. Pain Prevents me from lifting heavy weights but I can manage light weights if they are conveniently positioned. 4. I can only lift very light weights. 5. I cannot lift or carry anything at all. 4-WALKING 0. I can walk as far as I wish. 1. Pain prevents me from walking more than one mile. 7 Pai n pravp.nte ma from rnara than it 3. Pain prevents me from walking more than 'A mile. 4. I can walk only if I use a stick or crutches. 5. I am in bed or in a chair for most of every day. 5-SITTING 0. I can sit in any chair as long as I like. 1. I can sit in my favorite chair only, but for as long as I like. 2. Pain prevents me from s;h -;-g more than 1 hour. 3. Pain prevents me from sitting more than 1/2 hour. 4. Pain prevents me from silting more than 10 minutes. 5. Pain prevents me from sitting at all. 6-STANDING 0. I can stand as long as I want without extra pain. 1. I can stand as long as I want, but it gives me extra pain. 2. Pain prevents me from standing for more than 1 hour. 3. Pain prevents me from standing for more than 30 minutes. 4. Pain prevents me from standing for more than 10 minutes. 5. Pain prevents me from standing at all. 7-SLEEPING 0. Pain does not prevent me from sleeping well. 1.1 do not sleep well and I do not use tablets. 2. Even when I take tablets I have less than 6 hours sleep. 3. Even when I take tablets I have less than 4 hours sleep. 4. Even when I take tablets I have less than 2 hours sleep. 5. Pain prevents me from sleeping at all. 8-SEX LIFE O. I am not sexually active or my sexual activity is reduced but this is not because of pain. 0. My sex life is normal and causes no extra pain. 1. My sex life is normal but causes some extra pain. 2. My sex life is nearly normal but is very painful. 3. My sex life is severely restricted by pain. 4. My sex life is nearly absent because of pain. 5. Pain prevents any sex life at all. 9-SOCIAL LIFE 0. My social life is normal and causes no pain. 1. My social life is normal but increases the amount of pain. 2. Pain affects my sociai iife by limiting only my more energetic interests (dancing, baseball, tennis, ect.). 3. Pain has restricted my social life and I do not go out as often. 4. Pain has restricted my social life to my home. 5. I have no social life because of pain. 10-TRAVELING O. I can travel anywhere without extra pain. 1. I can travel anywhere but it gives me extra pain. 2. Pain is bad, but I manage journeys over 2 hours. 3. Pain restricts me to journeys of less than one hour. 4. Pain restricts me to short necessary journeys less than 30 minutes. 5. Pain prevents me from traveling except to the doctors or hospital.
6 Past Medical History ** CIRCLE ALL THAT APPLY ** ADHD AIDS/HIV Abuse/Domestic Violence Acid Reflux/GERD Allergies Anemia Anxiety Disorder Arthritis Asthma Autism Spectrum Disorder Back Injury Bi-Polar Disorder Birth Defects Bladder/Kidney Problems Bleeding Disorder Blood Disease Hernia High Cholesterol Hypertension Hyperthyroidism Hypothyroidism Insomnia Irritable Bowel Syndrome Kidney Disease Kidney Stones Liver Disease Lung Disease MRSA Exposure Mental Disorder Mental Illness Migraines Muscle, Joint or Bone Problems Blood Transfusion Breast Cancer Breast Problems Neuropathy Obesity Obsessive Compulsive Disorder COPD Cancer Chronic Back Pain Congestive Heart Failure Constipation Coronary Artery Disease Depression Development/Behavior Disorder Osteoporosis Other Ovarian Cancer PTSD Pancreatitis Plantar Fasciitis Pneumonia Polyps Diabetes Diverticulitis Ear/Hearing Problems Fating n! snrrior Eczema Endometriosis Fibromyalgia GI Problems Gout Head Trauma/Injury Headaches Heart Attack (Ml) Heart Disease Heart Problems Hepatitis Pulmonary Embolism Restless Leg Syndrome Scoliosis C/ cptiepsy Skin Problems Sleep Apnea Stroke Substance Abu:;e Thrombophilias Thyroid Problems Tuberculosis Ulcers Varicosities Vision or Eye Problems
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